Interprofessional Interagency Team Care at a Free Diabetes Clinic: Year 2 Progress Jennifer Frank, PhD, Brenda Iddins, DNP, FNP-BC, Michele Talley, MSN, ACNP-BC, Deepti Bahl, MD, Heidi Beck, MS, Matt Fifolt, PhD, Lisle Hites, MS, PhD, and Cynthia Selleck, PhD, RN, FAAN

UAB School of Nursing

Institute of Healthcare Improvement Triple Aim Improving the healthcare experience (quality and satisfaction) Improving the health of populations Reducing healthcare costs

M-POWER Ministries Literacy Center Health Center Education Center Only free clinic in Birmingham; open 3 evenings/week UABSON opened PATH Clinic 1 morning/week in May 2011

Objectives 1.Implement a model in which nurses and other health professionals become competent at interprofessional collaborative practice. 2.Demonstrate the efficacy of the Chronic Care Model in providing continuity of care and chronic disease management to a medically underserved population.

Objectives 3. Integrate nursing and other health professions students into the IPCP model in order to gain experience with team- based care and the healthcare needs of vulnerablepopulations. 4.Develop and implement a plan for intermediate and long-term success of the IPCP model at the PATH Clinic.

IPCP Staffing Plan Total of 1,614 patient visits from 431 unique patients in 2014 Tuesday – 773 visits Wednesday – 559 visits Thursday – 282 visits Tuesday Team Endocrinologist 2 Nurse Practitioners (NP) Registered Nurse (RN) RN Care Manager Dietitian PAP Coordinator Pharmacist Students Tuesday Team Endocrinologist 2 Nurse Practitioners (NP) Registered Nurse (RN) RN Care Manager Dietitian PAP Coordinator Pharmacist Students Wednesday Team Internist 2 NPs Optometrist 1 Psych/MH NP Psychiatrist RN RN Care Manager Dietitian PAP Coordinator Pharmacist Students Wednesday Team Internist 2 NPs Optometrist 1 Psych/MH NP Psychiatrist RN RN Care Manager Dietitian PAP Coordinator Pharmacist Students Thursday Team Internist with medical residents 1 NP RN RN Care Manager Dietitian PAP Coordinator Pharmacist Students Thursday Team Internist with medical residents 1 NP RN RN Care Manager Dietitian PAP Coordinator Pharmacist Students Data for Tuesday patients from December 2012 through December 2014

Project Innovations Collaboration and support of an Academic Medical Center Use of an Interprofessional Coach Incorporation of multiple disciplines, and students from each discipline Use of daily team huddles and post-conferences Recognition of need for RN Care Manager and PAP coordinator Sweet Home Alabama

PATH Clinic: Pre-Huddle Each morning begins with a pre-huddle All providers, staff, and students attend except triage nurses Patient list reviewed (time reduced to 15 min.) – New patients versus established patients Discuss potential issues with flow (staffing issues, dispensary issues, medication availability)

PATH Clinic: Patient Appointment Enter clinic and sign in at front desk Complete demographic info Complete HIPAA and Patient Covenant with M-Power and PATH clinic All new patients attend Diabetes Education Class for 1-2 hours with Dietitian who is a CDE All established patients wait until called into triage area

PATH Clinic: Patient Flow Patients called to triage area Triage nurse obtains height/weight, vital signs, labs, and chief complaint Patient escorted to exam room by triage nurse Patient seen by provider

PATH Clinic: Patient Appointment Provider (Nurse Practitioner or Physician) reviews previous records reviews glucometer, blood glucose trends, and dietary log conducts review of systems and physical exam establishes a plan with patient completes flow sheet with patient follow-up information

Clinic Process After the visit is complete, patients receive a flow sheet explaining other providers to be seen before leaving the clinic Patients take the flow sheet to the next provider (dietitian, nurse care manager, pharmacist, social worker/pharmaceutical patient assistance program manager) Follow-up appointment is made

Patient Instructions Form

PATH Clinic: Post-Huddle Post-huddle with all providers, staff, students Originally discussed each patient, now focus on high priority patients Patient Assistance Program coordinator works with providers so patients receive certain meds that are expensive Nurse care manager follows up with any missed appointments, necessary referrals, etc.

Tuesday Patient Demographics* 353 unique patients seen for a completed visit 1,826 visits scheduled 1,281 visits completed (1 – 20 per patient) 135 patients scheduled for a visit never came Data for Tuesday patients from December 2012 through March, 2015

Tuesday Referral Demographics Median Age at Referral = 47.02, Range years T1DM 15.8%

Patient Referral Criteria

Outcome Measures Resource Use Number of ED visits Number of Hospitalizations Total charges (costs) Clinical Outcomes A1C, BP, BMI PHQ-9 Depression scale Process Measures % clinic visits kept # clinic visits provided # services provided Health & Social Outcomes Successful enrollment in other care sites Obtaining health insurance Successful enrollment in PAP

Evaluation Instruments Alternating Monthly Provider Surveys – Survey of Organizational Attributes of Primary Care (SOAP-C) – Team Fitness Test Evaluation of Interprofessional Coaching sessions Structured interviews with providers on knowledge of Interprofessional Collaborative Practice (IPCP) Annual Assessment of Interprofessional Team Collaboration Scale survey

Results of Evaluation Emerging Themes – Knowledge of IPCP – Interactions between providers – Patient care

Knowledge about IPCP Providers had little knowledge of IPCP before starting at the PATH clinic By the end of Year 2, could demonstrate knowledge of the competency domains with real world examples from the clinic Described model as “collaborative, comprehensive, interactive”

Interactions between Providers Previous experiences were in physician- led hierarchical settings Indicated that their perceptions of other disciplines remained high or improved Some reported an increased respect for NPs

Patient Care Providers felt that IPCP model with direct communication improved patient care Multiple perspectives reinforced message to patients Model particularly effective with this population who have trouble with coordination of care

Clinical Outcomes (Tuesday) Comparing the same 250 patients for one year pre and post their first PATH visit – Inpatient Admission Rate decreased 57% (p<0.001) – Diabetes related diagnoses are the most frequent – ED rate increased by 20% (p<0.04)

Outcomes, continued Comparing the same 250 patients for one year pre and post their first PATH visit – Median total hospital cost per patient (across all admissions) increased ($9,403 versus $6,657) – Assumption that patients are admitted for more serious conditions – Total hospital costs decreased by 60% with savings of $1.5 million

Clinical Outcomes, 2014

Diabetes (n=254) Mean A1C on first clinic visit – 8.65 (SD=2.6) On final measurement at patient’s most recent visit Hypertension 152/319 patients with BP < 140/90 on last measurement

Clinical Outcomes, 2014 Services Provided Across Days Dilated Eye Exams – 141/431 Weight Screening and follow-up - 431/431 Patients Screened for Depression – 431/431 Patients treated for depression – 134/431 Flu Shots – 22/431 Tobacco cessation counseling - poor

Challenges to the Model Staff turnover Communication across clinic days EMR Lack of space/dispensary issues Overcoming misperception of “leaderless” model Sustainability

Lessons Learned Education – to understand shifting leadership Interagency cooperation - vital Care management – crucial for our population PAP Coordinator - essential for navigating pharmaceutical company charity programs Reduction in hospital costs – difficult to assess Sustainability - start early

Questions?